MECHAI VIRAVAIDYA
Population and Community Development Association (PDA), Bangkok,
Thailand

By the early 1970s, Thailand's population had
increased to an alarming level, with a growth rate that indicated
that the population would double by the end of the century.

Organized family planning programmes were
producing marginal results and it became clear that a new
systematic and concerted effort was needed to motivate the
public. New and innovative approaches were needed, and with this
in mind the author launched a nationwide social marketing
campaign designed to introduce and/or reintroduce family
planning, operating through the newly created Community-based
Family Planning Services (CBFPS), a major bureau of the
Population and Community Development Association (PDA).

In a systematic fashion, the social marketing
programme desensitized the population to the traditionally
sensitive issue of family planning, demonstrated the need for
family planning, and motivated people to use contraceptives that
were provided through community-based voluntary distributors.
Using local channels for communicating the family-planning
message, the programme was conducted in an atmosphere that
reflected its insight into Thai culture.

This paper will present a basic framework for a
social marketing programme, and as an illustration will relate
its various components to PDA's own experiences in contraceptive
and family-planning social marketing. It is hoped that this
framework will be of assistance in the design of social marketing
or communication programmes in other areas of health, such as
nutrition. The framework consists of four sections: social
preparation, communications, distribution/service provision, and
reinforcement/expansion.

SOCIAL RESEARCH AND PREPARATION

Social Research

Define Outcome Desired

It is imperative that the specific outcome and
changes in behaviour desired in the target population are clearly
defined. Attention to the final outcome(s) will focus the
direction of the social marketing programme and serve as a
reference for evaluation. It will also provide guidance for the
appropriate modification of the programme.

For a family-planning programme, the ultimate
goal is reducing the population growth rate. The specific
action-oriented result desired is the use of contraceptives. With
this firmly in mind, PDA's programme was not distracted by its
success in such steps as providing knowledge and making
contraceptives available. With the goal clearly defined the steps
are perceived in their proper perspective as prerequisites to the
desired outcome.

Analysis of Target Population

Because social marketing programmes seek to
modify existing behaviour, or encourage new practices, an
understanding of the existing baseline behaviour is necessary
before a social marketing programme can be appropriately
designed.

It is of vital importance to know whom the
programme is trying to reach and what the constraints affecting
health practices are. Particular attention should be paid to
those factors that impede or facilitate the desired behaviour: Is
knowledge lacking, are there accessibility problems, are there
economic difficulties or social/cultural barriers?

For example, through the social research
process it was found that the Thai population first needed to be
desensitized to the very issue of family planning. People were
afraid to talk about family planning and were embarrassed to buy
contraceptives. Therefore, one of the prerequisite behaviours
necessary to achieve the ultimate desired outcome was for the
target population to be able to talk openly and handle
contraceptives as normal household items. It was not until this
had been achieved that the next steps in the programme could be
taken.

Determining what motivates the target
population to carry out the desired behaviour, as well as what it
considers to be rewarding, is an essential part of background
research. Rewards may include social rewards such as praise,
recognition, or attention (possibly through publicity), tangible
rewards such as food or prizes, or behavioural rewards such as
engaging in enjoyable activities. An illustration of how
knowledge of the target population was used in PDA's social
marketing programme is reflected in the following example.

It was realized that vasectomy services were
not available in the villages and that some form of motivation
was also needed to spur people to final action. With these two
facts in mind, PDA developed a system whereby, if 15 men in a
village wished to have a vasectomy, PDA would pick them up in a
bus and drive them to PDA's clinic in Bangkok. After having
vasectomies, they were given a tour of Bangkok, many visiting it
for the first time, and were taken to the holiest of all places
for Thai Buddhists, the temple of the Emerald Buddha.

Social Preparation

Social preparation includes those activities
that are conducted prior to either the implementation of services
or the commencement of a directed communication programme, and
that serve to increase the programme's acceptability and
credibility.

Social preparation activities usually involve
visits to government officials, village headmen, village
committees, monks, and any other individuals or groups whose
interests are involved. During such visits, the goals and
objectives of the programme are explained and support is sought.
The basic objectives of social preparation are to: (a) establish
a trusting relationship with the community; (b) gain official
recognition through political and religious support; and (c)
create a favourable environment for a communication programme and
for the desired action to take place.

COMMUNICATIONS

The following steps are felt to be essential
components of any effective communication programme. Some steps
may occur simultaneously or in a different order from that
presented. They have been separated only to clarify the process
involved.

Choice of Media

Mass media, while able to relay knowledge and
information, have rarely had lasting effects as regards changes
in behaviour. PDA's decision to use individuals to communicate
family-planning messages was made for the following reasons: (a)
they are able to attract people's attention; (b) they can respond
to local conditions; (c) they have a greater capacity for
convincing people than have mass media; (d) they can generate a
rapport with the target group and develop a trusting
relationship; (e) the two-way communication made possible helps
ensure that family-planning messages are correctly understood.

Mass media, however, were used extensively to
communicate family-planning messages indirectly by carrying news
stories on PDA's promotion activities. These family planning
promotional events not only caught the attention of the target
population, but also of the news media as well. Such events
included: releasing hundreds of helium-filled balloons to which
were attached cards entitling the finder to a free vasectomy;
special Vasectomy Carnivals that included condom-blowing
contests, performances by local dramatic troupes extolling the
advantages of practicing family planning, and feature-film shows
with family-planning messages presented during the breaks; school
assembly meetings during which children recited family-planning
nursery rhymes, sang family-planning songs, and had
condom-blowing competitions.

Mass media were also used to inform the
population where services were available.

At the beginning of PDA's contraceptive social
marketing campaign, individual communicators/motivators presented
family-planning messages to large audiences at mass meetings held
for such groups as teachers, policemen, factory workers, and
government employees. These gatherings were light-hearted, with a
carnival-like atmosphere designed to make people laugh at what
was traditionally a sensitive issue. When services were being
instituted in villages, similar village-wide meetings were
organized to inform and motivate people to action.

After community-based services had been
established in a particular village, the voluntary distributor
assumed the responsibility for communicating family-planning
messages and for motivating individuals to use contraceptives.
These activities were usually carried out on a person-to-person
basis. By using local and well-respected people from communities
as distributors and communicators, family-planning messages were
adapted to meet local conditions and were more readily accepted.

Gaining and Maintaining the Target
Population's Attention

The key to gaining and maintaining attention is
to know the target group and to appeal to their interests using
active involvement, action, colour, and a sense of fun; this
requires the use of imaginative and varying approaches.

PDA's social marketing communication programme
made use of gimmicks, prizes and humour to catch people's
attention. Promotional T-shirts were produced with slogans such
as: Life Begins with Family Planning," and "Many
Children Make You Poor." Plastic-encased condoms, on which
was written: "In case of emergency, break glass." were
distributed for use as key chains. Condom-blowing contests made
people laugh and held their attention so that family-planning
messages could be delivered.

Removing Obstacles to Communication

In a social marketing communication programme
obstacles may be physical, economic, environmental. or social.
The predominant barrier to establishing an effective
family-planning programme in Thailand was the Thai people's
traditional avoidance of discussing human reproductive physiology
and their sensitivity to the issue of family planning.
Contraceptives were considered "dirty" and so the PDA's
social marketing spearhead was a desensitization campaign
designed to show people that family planning was only as dirty as
people's minds made it. A personal and direct approach was used:
actually putting condoms in people's hands so that they could see
for themselves and having people then blow them up in
condom-blowing competitions. One minute people were
self-conscious and the next they were laughing in the realization
that family planning was not something strange or mysterious at
all. Once people were desensitized, it was possible to
communicate and discuss family-planning issues. The Thais proved
to be very ready to listen when problems were presented in a
clear, concise, and simple manner.

Establishing How the Problem
Relates to the Individual

In PDA's family-planning programme, people
needed to be made aware of the rapidly increasing population. Not
all people, even among government officials, felt that a rapidly
increasing population posed a problem.

Messages on population growth were given as
clear facts, such as that the population of Thailand would double
by the end of the century if its growth rate were not reduced.
This was shown graphically by posters and T-shirts depicting an
earth so crowded that people were falling off.

Unless people feel that problems relate to them
directly and personally, it is unlikely that they will be
motivated to action. The slogan "Many Children Make You
Poor," as well as being clear and simple, related the
population issue to the individual. The advantages of raising two
children well (i.e. being able to provide good nutrition and
education) rather than raising many children under deprived
conditions were pointed out.

Demonstrating the Need for Action

In conjunction with presenting problems and
their relationship to the individual, it is important to foster a
perception of the serious consequences should one fail to act.

In promotion family planning, people were made
aware of the immediate results of having "too many"
children in their family and also the serious problems that would
result on a national level from uncontrolled population growth.

Action an Individual May Take

For a family-planning social marketing
programme, the required action is clear: use contraceptives.
People were therefore informed of the various types of
contraceptives available as well as where they could be obtained.

Convincing People that the
Suggested Actions Will Be Effective

Particularly with new concepts, individuals are
not willing to risk their time, money, security, or health if
they are not convinced of the efficacy of the proposed action.
Positive statements by well-knwon community members add
credibility, and once individuals take action their affirmation
of the effectiveness of that action reinforces support of the
programme. Proper education must be given so that action is
carried out in the proper manner, thus ensuring that the
anticipated outcome is achieved.

PDA's approach of first gaining the support of
local institutions and officials through its social preparation
phase helps to establish the credibility of the programme and of
the action that it advocates. A trusting relationship was more
easily established by associating the offered services with the
village temple. Thus, when a new shipment of contraceptives
arrives in a village it is not uncommon for the monk to bless
them. Promotional meetings and mobile vasectomy programmes are
also held at the temples.

Removing Obstacles to Action

Obstacles to action may be environmental,
logistical, social, or economic. Whereas the logistical and
economic difficulties may be minimized through an appropriately
designed distribution network incorporating alternate financing
schemes, the communication programme can be designed to reduce
social or cultural barriers.

As previously mentioned, it was necessary to
desensitize the Thai population to family planning as a
prerequisite to soliciting the desired action. Other obstacles
often arose through misinformation spread by rumours. Steps taken
to minimize rumours include anticipating them and counteracting
or exposing misinformation through education. The target
population must be made aware of the secondary effects of their
choice of action, and for family planning this includes giving a
full description of the side-effects of certain contraceptives.
In this way the sources of many rumours are removed.

DISTRIBUTION/SERVICE PROVISION

For social marketing programmes where the
desired outcome is the use of a product or service, it must be
presented to the potential user in such a way that the products
or services are readily available and acceptable. There are many
factors to consider in the delivery of goods or services, and
these have been well described and analysed in numerous
commercial marketing texts.

Acceptability

To increase the acceptability of
contraceptives, PDA used community-based volunteers who worked as
distributors and communicators. As they were respected members of
the community, they were trusted and in this way the services
offered through them were made more acceptable. The social
preparation phase of the social marketing programme also served
to increase the acceptability of services.

Availability

PDA's approach was to make contraceptives as
easily available as possible by using local channels.

Distribution points used have included: (a)
female boat vendors who sold pills and condoms as well as fruit
and vegetables; (b) vending machines making condoms available 24
hours a day; (c) urban taxi drivers; (d) factory nurses; (e) mail
order- also a good channel for those too shy to buy condoms from
a distributor; (f) pharmacies; (g) family-planning supermarkets
set up in bus and train stations; and (h) over 16,000
community-based volunteer distributors.

Sterilizations were conducted either through
PDA's Mobile Vasectomy Tour Bus Services or at one of four
clinics.

Price

It is PDA's philosophy that services will be
valued more highly if something is paid for them. Thus,
contraceptives are sold for a nominal amount and the revenue thus
generated is used to finance the cost of delivery services. For
motivational purposes the distributors also receive a small
commission on their sales.

Product

The condoms marketed by PDA under the brand
name "Mechai" are packaged in attractive, eye-catching
colours reflective of the cheerful promotional campaign that
accompanied them. A variety of brands are made available in the
belief that individuals like to exercise choice. In this way the
user feels that the final decision is his own rather than that he
is acting because he has been told to do so.

Similarly, with female oral contraceptives,
three brands are offered that are distinguished by colour: white,
silver, and gold. Although chemically similar, these brands have
different prices so that the consumer is able to make a choice.
In this way, if the users are not satisfied with one type, they
have the option to "try again" with a different brand
rather than simply discontinue the method.

Promotion

Promotion must be continuous if the message is
not to be forgotten. In order to do this on the village level,
PDA produces a multi-coloured poster every month and posters are
sent to every voluntary distributor for display in his or her
village. These posters provide information on issues and subjects
of interest to villagers, such as agriculture, appropriate
technology, water resource development, and health. The
information presented, as well as helping to better the
villagers' lives, draws them to read the family-planning messages
incorporated into the subject-matter.

The village volunteers are also upgraded
through specialized training programmes and some are now working
as government health communicators under their village health
development programme. At these courses the volunteers learn new
communication and motivation techniques in addition to skills
related to community development.

REINFORCEMENT AND EXPANSION

The marketing programme does not end once the
target population begins to practice the desired behaviour. The
behaviour must be reinforced in order to be maintained. It has
been found that intermittent reinforcement greatly diminishes the
potential extinction of the practice. Because the benefits
resulting from the practice of family planning are not
immediately tangible, it is crucial that those practicing it are
given support and reinforcement from the beginning.

As one benefit of using family planning is an
improved economic condition, PDA has used various income-raising
activities to reinforce or reward fertility management. The
acceptor, by using family planning, demonstrates a willingness to
take control over and responsibility for his or her own life, and
with this mature attitude people are also more likely to take
full advantage of an opportunity for economic betterment.
Communication materials can work in conjunction with
reinforcement activities so that the original purpose of the
programme is not lost through the addition of other services.

Examples of Some Reinforcement
Activities, Past and Present

1. Better Market Programme

Family-planning participants are given the
opportunity to sell their non-perishable products such as
coconuts, pumpkins, silk, and handicrafts to PDA, who, in turn,
finds a market for them and arranges transportation. By cutting
out the middleman the villagers get at least 30 per cent more for
their produce.

2. Pig-raising Programme

Male stud pigs are lent free of charge to
families practicing family planning who own one or more sows. The
resulting piglets are fed on the families' domestic scraps for
eight to nine months, during which time the family promises to
continue using their method of contraception. PDA then assists in
marketing the pigs with the sales profit given to the family.

Supporting communications: Stud pigs used in
the programme bear family-planning slogans on their flanks;
T-shirts are designed with the message "Let Your Next
Pregnancy Belong to the Pig."

3. Community-based Incentive Programme in
Thailand (CBIT)

To increase village-level contraceptive-use
prevalence rates, community incentives are introduced through
credit co-operatives. Preference for loans is given on the basis
of family-planning practice and method. As the village
contraceptive prevalence rates increase. PDA increases the size
of the loan fund. Currently there are six credit cooperatives in
north-east Thailand, three of which are run entirely by women.